AB1851 TERMINATION OF PREGNANCY IN LUPUS NEPHRITIS: A BIOETHICAL ANALYSIS WITH THE INTEGRATIVE METHOD
Authors: T. Cano-Gámez, A. Lobato-Belmonte, I. Peláez-Ballestas, G. Medrano Ramirez, J. De León-Carbajal, A. Manrique de Lara
Journal: Annals of the Rheumatic Diseases (2023)

<h3>Background</h3> Termination of pregnancy in patients with rheumatic diseases is controversial due to current lack of evidence. Around one fourth of pregnancies in patients with rheumatic diseases are terminated due to medical reasons. Only 0.026% of articles in Rheumatology relate to bioethics despite the high frequency of ethical dilemmas in the treatment of pregnant patients with autoimmune diseases. [1] <h3>Objectives</h3> To analyze from a bioethical perspective the case of a pregnant patient with lupus nephritis unresponsive to treatment, for whom termination of pregnancy is considered as a therapeutic measure. <h3>Methods</h3> The integrative model was applied combining different normative ethical theories. The central moral dilemma and main stakeholders were identified. The case was analyzed from utilitarian, deontological and virtue ethics perspectives, followed by integration to establish a global conclusion. <h3>Results</h3> <i>Case presentation.</i> A 30-year-old woman was diagnosed with systemic lupus erythematosus in 2019 in Mexico. Induction therapy for lupus nephritis was started; however, it was interrupted due to COVID-19 pandemic. When she returned for follow-up, despite treatment was reinstated, she persisted with proteinuria without achieving complete remission criteria. Multi-target therapy was started; however, patient stopped treatment for economic reasons and became pregnant shortly after. She presented for prenatal control follow-up at 20 gestational weeks with edema in the lower extremities and hypertension, for which she was hospitalized in intensive care. Renal replacement therapy was initiated without further response to treatment. A multidisciplinary team suggested pregnancy termination as a therapeutic option, which the patient refused. <i>Bioethics analysis.</i> Figure 1 shows the background factors and initial steps for defining and analyzing the bioethical dilemma. Three different normative ethical theories were used. <i>Utilitarianism</i>. The consequences of the action are the central component, and the decisions made must be profitable and effective for the majority. Terminating the pregnancy would seek to protect the mother's life, since saving one life represents a greater benefit than losing two. For the patient's family, the costs of continuing with the pregnancy would be unsustainable. For the institution, the termination of the pregnancy would lead to a more efficient use of human and material resources. Therefore, interrupting the pregnancy is justifiable. <i>Deontology</i>. Duty-based ethics center the action itself regardless of consequences, as well as valuing autonomy. Seeking all therapeutic alternatives, including termination of pregnancy, is a good action itself. However, considering the patient's autonomy, her desire to continue pregnancy must be taken into account. Therefore, both terminating and continuing the pregnancy are justifiable. <i>Virtue ethics.</i> Aretology centers the importance of decisions in the person who performs the action. Core values involve enabling flourishing and personal growth. For both the family and the institution, flourishing would imply preserving the life of the patient. Therefore, the termination of pregnancy is justifiable. <h3>Conclusion</h3> Using the integrative method, we conclude that termination of the pregnancy is justifiable from the three ethical theories and is an appropriate resolution to the ethical dilemma. However, considering the patient's desire to continue pregnancy, health professionals should offer psycho-emotional support. The lack of recommendations about medically indicated termination of pregnancy in rheumatology leads to complex moral decisions, making the bioethical analysis of paradigmatic cases essential to ensure the best possible action and as a precedent for future similar situations. <h3>Reference</h3> [1] Caplan, L., Hoffecker, L. and Prochazka, A.V. (2008) "Ethics in the rheumatology literature: A systematic review," Arthritis &amp; Rheumatism, 59(6), pp. 816–821. Available at: https://doi.org/10.1002/art.23703. <h3>Acknowledgements</h3> We thank the patient and her family for allowing us to use their experience as a tool for education and learning. We thank Dr. Conrado García García for facilitating clinical information. <h3>Disclosure of Interests</h3> None Declared.